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Record the Client's Presenting Concerns
On the
Presenting Concerns
panel, do one of the following actions in the
Written HPI narrative
field:
Use the client's words to document the symptoms and presenting issues that prompted a visit to the office.
Use the My Phrases functionality.
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Record the Client's Presenting Concerns
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record a Risk Assessment
Any assessment of risk data that was entered previously on the Comprehensive Assessment template set carries forward to the panels found here. On the Risk Assessment panel, if the patient is not a danger to self or other, select the option for Patient is not currently a danger to self, others, or property. Selecting this option sets every field in the section as unavailable. The Encounter field fills with the current date. In the Risk field, select the appropriate type of risk from the list. If there is a need to record a previous risk for the client, select the Past option. CAUTION: Always document past risks before a current assessment. If Past is selected, either an Event Date (even if approximate) or Denied should be populated. If there are no past assessments to document, select the option for Current. Select Denied or Admits. If Denied is selected, the documentation options are all disabled in this section except for the date fields and the Add and Clear buttons. Enter the Event
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record Mental Status Exam Information
For a more comprehensive record than is offered on the Mental Status Evaluation panel, click the Mental Status Exam link. The BH - Mental Status Exam template opens. Note: The determination to perform a full exam should be made by the provider. Alternatively or in addition, a mental status narrative, including the client's appearance, mood, affect, speech, thought process/content, cognition, and insight/judgement can be entered in the Written narrative field. Parent topic: BH - Brief Assessment Template
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Record the Client's Presenting Concerns
Use the client's words to document the symptoms and presenting issues in the Presenting Concerns panel. In the Presenting Concerns panel of the BH CA Presenting Concerns template, enter an explanation for this visit to the office in the Reason for referral field. Click the My Phrases link to select a sentence to enter in the Reason for referral field. For more information on My Phrases, go to NextGen Healthcare Success Community, and download the Getting Started User Guide for NextGen® Adaptive Content Engine. Parent topic: Intake Process for Comprehensive Assessment
NextGen Behavioral Health Suite Help 5.5
Document the Patient's Presenting Concerns
Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Comp Assess - Concerns, and then select OK. Document whether the assessment is the initial assessment or an annual update to an existing assessment. In the Individuals Present panel, document the details of the individuals present during the assessment. In the Presenting Concerns panel, enter the details of the patient's current concerns and the required help. Parent topic: Document the Patient's Intake Notes Using the Comprehensive Assessment Templates
NextGen® Adaptive Content Engine Help Enterprise 8.3.1
Enter Psychiatric Evaluation Presenting Concerns
The Presenting Concerns panel enables you to document the symptoms and presenting issues, in the client's own words, which prompted a visit to the office in the Reason for referral field. In the Presenting Concerns panel select No or Yes to answer the question: Comprehensive Assessment has been completed. If Yes, enter the date of the most recent assessment into the field. In the Reason for referral and chief complaint field, click to enter or dictate notable symptoms, presenting problems, behavioral and functional needs, etc. Enter Family/guardian description of problem. For History of present psychiatric illness, do one of the following actions: Select None reported. Enter or dictate history details. Parent topic: BH - Psychiatric Evaluation
NextGen Behavioral Health Suite Help 5.5
Document Patient's Mental Health Details Using the Brief Assessment Template
Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates. The Select Template window opens. On the Medical Records tab, select All. From the list, select Brief Assessment (BH), and then select OK. Select the program, specialty, and visit type for the patient. Select whether you have discussed confidentiality and obtained patient's consent for the care. To document the patient's past medical history, select the History Summary link. In the Presenting Concerns panel, do one of the following actions in the Written HPI narrative field: Enter the patient's symptoms and presenting issues that prompted a visit to the office. Use the My Phrases link to select the details for the visit. In the Substance Use/Addictive Behavior panel, select the patient's addiction details to substances. Select the patient's current experiences on physical and domestic violence and other trauma details in the Trauma History panel. Enter the patient's mental status evaluation findings. Comp
